Case report
In the case report, we present a case of a 13-year-old patient with
chronic debilitating fatigue who meets the criteria for CFS/ME. The
patient was examined in detail by a paediatrician (anamnestic unclear
cause, resting tachycardia in the physical examination, laboratory tests
within normal limits), endocrinologist (normal hormonal profile for a
given age, Tanner stage 3), infectologist (serology for typical viruses
negative), psychologist (normal cognitive functions). For a history of
resting tachycardia, the patient was examined by a cardiologist where no
cardiogenic cause of fatigue was demonstrated, sinus tachycardia was
present, and the patient was recommended head-up-tilt test, which showed
the presence of postural orthostatic tachycardia. Due to the idiopathic
nature of the difficulties and the excluded secondary cause, a two-day
protocol examination by cardiopulmonary exercise testing was indicated.
Written consent was taken and documented. Before the examination,
resting spirometry (physiological findings) was performed, resting ECG
(sinus tachycardia) and a shortened Schellong test with a tachycardic
response to orthostasis immediately after standing up and after 3
minutes of standing. Subsequently, standard CPET using a treadmill
(Itam, Poland) with individualized protocol with progressive increase in
workload until exhaustion and breath-by-breath analysis of exhaled gases
(Geratherm, Germany) was performed. On the first day, basal values were
determined, the patient subjectively tolerated the examination well, the
exercise ended prematurely due to subjective fatigue and a feeling of
lack of air. On the second day, under the same conditions, CPET was
repeated, during which the patient also terminated the exercise
prematurely, but a half minute later than on the first day. Using this
methodology, the patient did not meet the diagnostic criteria for PEM
and subsequently CFS/ME (decrease in monitored values on the second day
of examination) (table 1). On both days, during exercise, a bizarre
pattern of respiration with malposition of the respiratory act to the
large airways was observed by observing the flow-volume loop. An
analysis of the respiratory pattern identified an erratic respiratory
pattern (figure 1a) with low resting ETCO2 (table 1) and tachypnoea at
maximal workload with dominant ventilation of dead space (figure 1b,
1c). The consequence of this pattern of respiration is a chronic state
of hypocapnia and respiratory alkalosis, which is metabolically
compensated in the patient. Fatigue and increased heart rate are
expected clinical manifestations. Respiratory rehabilitation was
recommended to the patient in order to fixate the correct breathing
patterns (diaphragmatic breathing) and psychological guidance. The
patient was subsequently retested 3 months after the start of
physiotherapy and psychotherapy at the request of the parents. Retesting
showed significant improvements in the monitored parameters (table 1) as
well as in the clinical condition of the patient. The patient’s overall
fitness increased, an adequate resting respiratory pattern was present
(figure 1d), ventilatory efficiency was adjusted (VE/VCO2 in table 1,
figure 1f), and the patient reported a subjective increase in energy.
Prior to the examination, we performed a Schellong test on the patient,
in which there were no signs of postural orthostatic tachycardia.